A Cost Calculation of EVAR and FEVAR Procedures at an European Academic Hospital.

BACKGROUND: The aim was to calculate the costs of EVAR and FEVAR procedures in a European academic hospital by cost retrieval based on a subcohort with known detailed costs through application of the individually detailed calculated costs to the total study population and to correlate these with corresponding reimbursements. METHODS: A cost analysis was performed on 25 FEVAR and 100 EVAR cases based on the detailed cost analysis of a group of patients treated in 2012 and 2013 by applying the costs based on costs per time unit within 4 subgroups: (1) uncomplicated EVAR, (2) complicated EVAR, (3) uncomplicated FEVAR, and (4) complicated FEVAR. RESULTS: Thirty cases (19 EVAR and 11 FEVAR) treated in 2012 and 2013 were used to determine the individual detailed costs for the entire study group consisting of 100 EVAR and 25 FEVAR cases. There were 14 repeat operations within the 100 EVAR cases and 3 repeat operations within the 25 FEVAR cases. A total of 14 EVAR-treated patients were readmitted, as was one FEVAR patient. The costs of the endografts were the largest contributor to the overall costs, followed by the costs of the surgery itself and the stay in the ward. The costs of an uncomplicated EVAR procedure summed up at €12,090; a complicated EVAR procedure costs €13,956. An uncomplicated FEVAR procedure costs €34,807, and a complicated FEVAR procedure costs €36,695. The difference between median reimbursements received for the uncomplicated EVAR and FEVAR procedures was significant with €13,374 for uncomplicated FEVAR and €11,486 for complicated FEVAR in favor of the FEVAR group (P < 0.05). CONCLUSIONS: No financial loss was calculated in any of the subgroups. The costs of the endografts were the largest contributor to the overall costs, followed by the costs of the surgery itself and the stay in the ward.

Gender-based 30-day and long-term outcomes after carotid endarterectomy.

BACKGROUND: We analyses the effect of gender on short and long-term morbidity and mortality in carotid endarterectomy (CEA) under loco-regional anesthesia. PATIENTS AND METHODS: Patients who were entered into a prospectively compiled computerized database of unilateral, consecutive CEAs performed at our hospital from January 2000 to December 2010 were analysed. Endpoints were perioperative stroke and death, and overall long-term survival rates. Statistical analysis was used to determine the relationships between gender and outcomes after CEA. A Cox proportional hazard model was applied to determine independent risk factors for long term survival. RESULTS: A total of 1880 CEA procedures were performed in the period between 2000 and 2010. Overall, there were 28 (1.48 %) neurological deficits according to the ipsilateral carotid supply territory, including minor and major strokes. 7 occurred in the female group (1.19 %), and 21 in the male group (1.62 %) with no significant difference between the genders (p = 0.60). No significant difference emerged between female and male patients when postoperative neurological events according to the ipsilateral carotid supply territory were stratified by linical presentation (asymptomatic ICA stenosis: p = 0.75; symptomatic ICA stenosis: p = 0.66). The late overall mortality rate was 4.1% (n = 78) and 26/78 of these late deaths occurred in the female group (33 %). Log rank analysis of Kaplan Meier curves showed no statistically significant difference in long-term survival between the groups (p = 0.74). The multivariate risk factor analysis with the Cox proportinal hazard model revealed age (p < 0.00), and smoking (p = 0,02) as independent risk factors for decreased long term survival. CONCLUSIONS: When considering short and long-term outcomes in patients receiving carotid endarterectomy in local anaesthesia gender should not be regarded as a factor on decision-making for carotid interventions in both symptomatic and asymptomatic patients.

The presence of variant genotype of the mannose-binding lectin gene (MBL2) is not associated with increased restenosis rate in carotid surgery.

BACKGROUND: We investigated the role of mannose-binding lectin (MBL) variant genotypes in patients with significant carotid restenosis after carotid endarterectomy (CEA) and who underwent a revision CEA. METHODS: This was a cross-sectional analysis of 97 patients enrolled between 2001 and 2013. Three groups were investigated: group A included patients with internal carotid artery restenosis, group B included patients without restenosis after CEA, and group C included patients with peripheral arterial disease but without any signs of a carotid stenosis. Venous blood samples were drawn for the genotyping for MBL2 by polymerase chain reaction and for the determination of the MBL serum concentration by enzyme-linked immunoabsorbent assay. RESULTS: The serum concentration of MBL was higher in patients with the normal genotype than in those with the genotype variants of MBL (95% confidence interval, 272.8-1008.7 µg/L; P = .001). There was no statistically significant difference among groups A, B, or C with respect to the presence of a variant genotype. Similarly, there was no significant gender difference regarding the presence of a variant genotype (P = .325). CONCLUSIONS: The presence of a variant genotype of the MBL2 gene (and the correspondingly lower serum concentration of this molecule) was not correlated with the development of carotid restenosis after CEA beyond a follow-up of 12 months.

Debate: Whether level I evidence comparing thoracic endovascular repair and medical management is necessary for uncomplicated type B aortic dissections.

Type B aortic dissections continue to be one of the most challenging clinical scenarios confronting vascular surgeons. In the era of open surgery, the therapeutic options were limited to medical management of hypertension and large open thoracoabdominal operations. In the current endovascular era, the operative strategies have become less invasive but the questions regarding therapeutic approaches have become more numerous and complex. In patients with acute uncomplicated type B aortic dissections, we are still unsure as to which patients are best treated with medical therapy alone or with the addition of early endovascular repair. Data from single centers and registries have provided some guidance; however, questions remain. Perhaps level 1 evidence from well-designed randomized controlled trials will answer all of our questions. This is the topic of the current debate.

Clinical significance of nm23 gene expression in gastric cancer.

BACKGROUND: The expression of the nm23 gene has been associated with the development of metastasis. Numerous studies have shown down-regulation of nm23 expression in metastatic breast and colon cancer. The expression of the putative metastasis-suppressor gene nm23 in gastric carcinoma is controversial. The aim of this study was the analysis of nm23 expression in a large series of gastric cancer patients. PATIENTS AND METHODS: In a retrospective immunohistochemical study specimens obtained from 116 gastric cancer patients (mean age 64 years; range: 33-85) who had undergone gastrectomy with extended lymphadenectomy were analyzed. Nm23 expression in the tumor epithelium was studied by immunohistochemistry followed by a semi-quantitative (score 0-3) evaluation. Statistical analysis including Chi-square test, uni- and multivariate survival analyses were performed. RESULTS: The nm23 staining pattern was positive (score 2-3) in 100 (86.2%) specimens and negative (score 0-1) in 16 (13.8%) samples. Lymph node metastasis was found in 65% of the patients. No significant correlations could be determined between nm23 expression and other variables such as gender, age, tumor differentiation, WHO-, Laurén-, Goseki-, or Ming-classification. The intensity of nm23 staining in the tumor cells was not significantly correlated with depth of tumor infiltration (T-stage), lymph node metastasis (N-stage), distant metastasis (M-stage), UICC-stage, or prognosis. CONCLUSION: Our series did not show a correlation of nm23 expression in terms of lymph node and distant metastasis or prognosis in gastric cancer patients.

Evaluation of POSSUM scoring system in patients with gastric cancer undergoing D2-gastrectomy.

BACKGROUND: Risk adjustment and stratification play an important role in quality assurance and in clinical research. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) is a patient risk prediction model based on 12 patient characteristics and 6 characteristics of the surgery performed. However, because the POSSUM was developed for quality assessment in general surgical units, its performance within specific subgroups still requires evaluation. The aim of the present study was to assess the accuracy of POSSUM in predicting mortality and morbidity in patients with gastric cancer undergoing D2-gastrectomy. METHODS: 137 patients with gastric cancer undergoing gastrectomy were included in this study. Detailed, standardized risk assessments and thorough documentation of the post-operative courses were performed prospectively, and the POSSUM scores were then calculated. RESULTS: The 30- and 90-day mortality rates were 3.6% (n = 5) and 5.8% (n = 8), respectively. 65.7% (n = 90) of patients had normal postoperative courses without major complications, 14.6% (n = 20) had moderate and 13.9% (n = 19) had severe complications. The number of mortalities predicted by the POSSUM-Mortality Risk Score (R1) was double the actual number of mortalities occurring in the median and high-risk groups, and was more than eight times the actual number of mortalities occurring in the low-risk group (R1 < 20%). However, the calculated R1 predicted rather well in terms of severe morbidity or post-operative death in each risk group: in predicted low risk patients the actual occurrence rate (AR) of severe morbidity or post-operative death was 14%, for predicted medium risk patients the AR was 23%, and for predicted high risk patients the AR was 50% (p < 0.05). The POSSUM-Morbidity Risk Score (R2) overestimated the risk of morbidity. CONCLUSION: The POSSUM Score may be beneficial and can be used for assessment of the peri- and post-operative courses of patients with gastric carcinoma undergoing D2-gastrectomy. However, none of the scores examined here are useful for preoperative prediction of postoperative course.

Early elective surgery for bleeding ulcer in the posterior duodenal bulb. Own results and review of the literature.

BACKGROUND/AIMS: Acute upper gastrointestinal bleeding represents the major, potentially life-threatening complication of gastroduodenal ulcer disease with an average mortality of 10%. To decrease mortality a risk-dependent combined endoscopic and operative approach for the treatment of bleeding ulcer in the posterior duodenal wall was developed. METHODOLOGY: Between 1998 and 2000 in our hospital a total of 22 patients with bleeding posterior duodenal bulb ulcer were treated following a differentiated endoscopic-surgical concept. High-risk patients with high bleeding activity (n = 8) underwent early elective surgery after primary endoscopic treatment of the bleeding and stabilization of the patient in an intensive care unit. The management of patients presenting a low-risk profile (n = 14) included careful surveillance and a consecutive second endoscopy 24 hours after the initial endoscopy. RESULTS: Patients that underwent surgery showed more severe secondary diseases than patients of the endoscopic group. Hemoglobin concentration in patients requiring surgery was significantly lower, they showed a higher incidence of hypovolemic shock and received more blood transfusions within the first 24 hours. Mortality was 0% in both groups, a relevant rebleeding occurred in one patient after endoscopic therapy, which was successfully treated by reendoscopy with fibrin injection. CONCLUSIONS: Due to these results as well as results of other groups we recommend early elective surgery in high-risk patients with bleeding duodenal bulb ulcer after primary endoscopic treatment of the bleeding.